The association of psoriasis with rheumatic diseases: A national cross-sectional study
Authors: Mimi Chung, Jared Liu, Samuel Yeroushalmi, Erin Bartholomew, Marwa Hakimi, Lianne S. Gensler, Tina Bhutani, Wilson Liao
Journal: Journal of the American Academy of Dermatology (2023)

To the Editor: Patients with psoriasis have an increased risk for comorbidities such as cardiometabolic disease and psoriatic arthritis.1Yamazaki F. Psoriasis: comorbidities.J Dermatol. 2021; 48: 732-740https://doi.org/10.1111/1346-8138.15840Crossref PubMed Scopus (39) Google Scholar However, the association of other rheumatic diseases with psoriasis remains to be fully elucidated. We conducted a cross-sectional cohort study in the United States-based racially and ethnically diverse All of Us (AoU) national database (∼40% non-White; https://allofus.nih.gov), investigating the association between psoriasis and rheumatic diseases. Subjects were adults aged 18 and older with electronic health records (EHRs) in the AoU database. Two cohorts, including a psoriasis (PsO) group (2 or more ICD9/10 diagnoses of psoriasis) and a control group (individuals without a diagnosis of PsO), were identified on May 14, 2022. Rheumatic diseases of interest (axial spondyloarthritis [axSpA], dermatomyositis [DM], fibromyalgia [FM], gout, osteoarthritis [OA], polymyositis [PM], psoriatic arthritis [PsA], rheumatoid arthritis [RA], Sjogren's syndrome [SS], systemic lupus erythematosus [SLE], and systemic sclerosis [SSc]) were identified according to ICD9/10 coded criteria (Supplementary Table 1, available via Mendeley at https://doi.org/10.17632/5hbv6s26fd.1). Data from participant surveys, including age, sex at birth, race, and ethnicity, smoking history, alcohol use history, income, and rural location were extracted. R version 4.1.2 was used to analyze information provided in the All of Us (AoU) database using EHR data for PsO patients and non-PsO controls. The Benjamini–Hochberg procedure was used to correct for multiple testing. Demographic data are shown in Table I, and univariate and multivariate analysis are summarized in Table II. After controlling for age, race, ethnicity, obesity, smoking, alcohol, income, and delay in care due to rural location, there was a significant association of PsO with psoriatic arthritis (PsA), osteoarthritis (OA), gout, fibromyalgia (FM), rheumatoid arthritis (RA), AS, Sjogren's syndrome (SS), and systemic sclerosis (SSc). There was a significant and strong association of PsO with CD but not UC, which was performed as an internal control. Due to clinical overlap between PsA and other rheumatic conditions, we examined the percentage of PsA patients diagnosed with concomitant diseases (Supplementary Table 3, available via Mendeley at https://doi.org/10.17632/5hbv6s26fd.1). Common co-diagnosis in PsA patients includes OA (47.6%), RA (15.1%), and FM (12.7%).Table IDemographics for psoriasis (PsO) patients versus nonpsoriasis controls. P-values calculated using χ2 statistics. For each variable examined, the totals reflect number of patients without missing dataPsOControlsP-valueTotal (n)3267265,957–Age, mean (SD)62.28 (14.72)54.69 (16.67)<1.00e-5BMI, mean (SD)30.81 (7.39)29.76197 (7.48)<1.00e-5Obesity (BMI > 30), n (%)<1.00e-5 Nonobese1658 (52.62%)153719 (59.22%) Obese1493 (47.38%)105840 (40.78%)Age group, n (%)<1.00e-5 18-44527 (16.13%)85550 (32.17%) 45-651167 (35.72%)100173 (37.67%) >651573 (48.15%)80234 (30.17%)Sex at birth, n (%).35 Male1295 (40.26%)103441 (39.43%) Female1923 (59.74%)158916 (60.57%)Race, n (%)<1.00e-5 White2390 (85.11%)131409 (61.87%) Black or African American229 (8.16%)63166 (29.74%) Asian88 (3.13%)8442 (3.97%) Other∗Defined as a sum of the answer choices "Another single population", "More than one population", and "None of these".101 (3.60%)9386 (4.41%)Ethnicity, n (%)<1.00e-5 Not Hispanic/Latinx2706 (85.41%)203763 (78.94%) Hispanic/Latinx462 (14.58%)54347 (21.1%)Alcohol use (ever), n (%)<1.00e-5 Yes2973 (92.91%)226189 (87.64%) No227 (7.09%)31883 (12.35%)Alcohol use within past year, n (%)5.03e-4 Yes2345 (72.53%)182515 (69.97%) No888 (27.47%)79324 (30.03%)Cigarette use (>100 cigarettes/lifetime), n (%)<1.00e-5 Yes1561 (48.87%)106697 (41.61%) No1633 (51.13%)149704 (58.39%)Annual income level<1.00e-5 Low (<$50k)1246 (44.7%)118397 (56.7%) Middle ($50k-$150k)1070 (38.4%)66201 (31.7%) High (>$150k)470 (16.9%)24145 (11.6%)Rural†Defined as a participant-reported delay in care due to living in a rural location..62 No1616 (97.23%)89964 (97.14%) Yes46 (2.76%)2762 (2.86%)BMI, Body mass index; n, number; PMD, patient missing data; PsO, psoriasis; SD, standard deviation.∗ Defined as a sum of the answer choices "Another single population", "More than one population", and "None of these".† Defined as a participant-reported delay in care due to living in a rural location. Open table in a new tab Table IIPrevalence and odds ratio (OR) of concomitant musculoskeletal and rheumatologic diseasesPsO(% of total)Controls(% of total)Univariate OR (95% CI)Univariate P-valueMultivariate OR∗Multivariate analysis controlled for age group, race, ethnicity, obesity, smoker, alcohol use within the past year, income level, and delay in care due to rural location. (95% CI)Multivariate P-valuePsA705 (21.6%)314 (0.1%)146.46 (119.95-179.58)<2e-16135.02 (108.25-169.27)<2E-16OA1233 (37.7%)41289 (15.5%)2.56 (2.30-2.85)<2e-162.23 (1.97-2.53)<2E-16Gout192 (5.9%)5118 (1.9%)2.45 (1.90-3.10)5.63E-132.15 (1.63-2.78)1.78E-08FM219 (6.7%)5628 (2.1%)2.96 (2.38-3.64)<2e-162.82 (2.21-3.56)<2E-16SLE54 (1.7%)2124 (8.0%)1.32 (0.74-2.17)0.3011.19 (0.59-2.12)0.59RA193 (5.9%)4089 (1.5%)3.70 (2.91-4.63)<2e-163.33 (2.54-4.29)<2E-16AxSpA33 (1.0%)367 (0.1%)5.76 (3.30-9.36)3.37E-115.19 (2.78-8.91)2.35E-08SS74 (2.3%)1972 (0.7%)2.25 (1.57-3.11)3.55E-061.93 (1.28-2.80)9.41E-04SSc<20†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.<400†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.3.12 (1.32-6.20)0.00352.93 (1.14-6.16)0.01PM<20†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.<200†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.3.41 (0.55-11.26)0.092.28 (0.13-10.93)0.42DM<20†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.<100†Exact values not reported to protect patient privacy, as per the All of Us database user agreements.2.37 (0.39-7.68)0.232.96 (0.48-9.81)0.14CD90 (2.8%)1581 (0.6%)3.30 (2.29-4.58)1.21E-113.11 (2.06-4.49)9.44E-09UC57 (1.7%)1530 (0.6%)1.59 (0.95-2.46)0.05511.09 (0.56-1.89)0.78AxSpA, Axial spondyloarthritis; CD, Crohn's disease; CI, confidence interval; DM, dermatomyositis; FM, fibromyalgia; OA, osteoarthritis; OR, odds ratio; PM, polymyositis; PsA, psoriatic arthritis; PsO, psoriasis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SS, Sjogren's syndrome; SSc, systemic sclerosis (scleroderma); UC, ulcerative colitis.∗ Multivariate analysis controlled for age group, race, ethnicity, obesity, smoker, alcohol use within the past year, income level, and delay in care due to rural location.† Exact values not reported to protect patient privacy, as per the All of Us database user agreements. Open table in a new tab BMI, Body mass index; n, number; PMD, patient missing data; PsO, psoriasis; SD, standard deviation. AxSpA, Axial spondyloarthritis; CD, Crohn's disease; CI, confidence interval; DM, dermatomyositis; FM, fibromyalgia; OA, osteoarthritis; OR, odds ratio; PM, polymyositis; PsA, psoriatic arthritis; PsO, psoriasis; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; SS, Sjogren's syndrome; SSc, systemic sclerosis (scleroderma); UC, ulcerative colitis. The association of PsO with systemic conditions is a growing focus because of its impact on the overall wellbeing of patients beyond the skin manifestations. Co-occurrence of psoriasis and rheumatic diagnoses may in part be due to common underlying mechanisms such as higher BMI.2Kulkarni K. Karssiens T. Kumar V. Pandit H. Obesity and osteoarthritis.Maturitas. 2016; 89: 22-28https://doi.org/10.1016/j.maturitas.2016.04.006Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar, 3D'Onghia M. Ciaffi J. Lisi L. et al.Fibromyalgia and obesity: a comprehensive systematic review and meta-analysis.Semin Arthritis Rheum. 2021; 51: 409-424https://doi.org/10.1016/j.semarthrit.2021.02.007Crossref PubMed Scopus (24) Google Scholar, 4Armstrong A.W. Harskamp C.T. Armstrong E.J. The association between psoriasis and obesity: a systematic review and meta-analysis of observational studies.Nutr Diabetes. 2012; 2e54https://doi.org/10.1038/nutd.2012.26Crossref PubMed Scopus (350) Google Scholar, 5Han J.H. Lee J.H. Han K.D. et al.Increased risk of psoriasis in subjects with abdominal obesity: a nationwide population-based study.J Dermatol. 2019; 46: 695-701https://doi.org/10.1111/1346-8138.14939Crossref PubMed Scopus (19) Google Scholar In our analysis, obesity as an independent covariate was significantly associated with an increased risk of all joint diagnoses investigated (PsA, OA, gout, RA, and AxSpA) as well as FM (Supplementary Table 2, available via Mendeley at https://doi.org/10.17632/5hbv6s26fd.1). Of note, however, PsO was associated with an increased odds of rheumatic diseases compared to controls even after adjustment for body mass index (BMI). The strength of this cross-sectional study is the inclusion of a relatively diverse set of patients in the AoU database, which allows our conclusions to be more generalizable. However, the potential for misclassification by incorrect diagnoses in the EHR is a limitation, especially regarding rheumatic disease in relation to PsA. The study was cross-sectional, limiting analysis of the temporal relationship between PsO and these rheumatic diseases. Overall, this study suggests the importance of screening PsO patients for MSK symptoms and referral to a rheumatologist if warranted. Tina Bhutani is a principal investigator for trials sponsored by Abbvie, Castle, CorEvitas, Dermavant, Galderma, Mindera, and Pfizer. She has received research grant funding from Novartis and Regeneron. She has been an advisor for Abbvie, Arcutis, Boehringer-Ingelheim, Bristol Myers Squibb, Janssen, Leo, Lilly, Novartis, Pfizer, Sun, and UCB. Wilson Liao has received research grant funding from Abbvie, Amgen, Janssen, Leo, Novartis, Pfizer, Regeneron, and TRex Bio. Lianne S. Gensler has received grant funding from Novartis, Pfizer and UCB and has been an advisor for AbbVie, Eli Lilly, Fresenius Kabi, Gilead, Janssen, MoonLake, Novartis, Pfizer and UCB. The remaining authors have nothing to disclose. The All of Us Research Program is supported by the following: the National Institutes of Health, Office of the Director: Regional Medical Centers: 1 OT2 OD026549; 1 OT2 OD026554; 1 OT2 OD026557; 1 OT2 OD026556; 1 OT2 OD026550; 1 OT2 OD 026552; 1 OT2 OD026553; 1 OT2 OD026548; 1 OT2 OD026551; 1 OT2 OD026555; IAA #: AOD 16037; Federally Qualified Health Centers: HHSN 263201600085U; Data and Research Center: 5 U2C OD023196; Biobank: 1 U24 OD023121; The Participant Center: U24 OD023176; Participant Technology Systems Center: 1 U24 OD023163; Communications and Engagement: 3 OT2 OD023205; 3 OT2 OD023206; and Community Partners: 1 OT2 OD025277; 3 OT2 OD025315; 1 OT2 OD025337; 1 OT2 OD025276. We thank all the participants of All of Us for their invaluable participation and collaboration with this program.